Inspection Reports for Country Gardens Union City
7175 Lester Rd, Union City, GA 30291, USA, GA, 30291
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
Moderate
Unclassified
Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 1, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50005619. An on-visit was made to the facility on 2025-09-24, and the investigation was completed on 2025-09-25.
Findings
No violations were cited as a result of the investigation. However, deficiencies were found related to workforce qualifications and training, including lack of current certification in emergency first aid and CPR for 3 of 3 sampled staff, and failure to ensure continuing education completion for the same staff.
Complaint Details
Investigation was initiated based on intake #GA50005619. The investigation started on 2025-09-24 and was completed on 2025-09-25. No violations were cited as a result of the investigation.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure evidence of current certification in emergency First Aid and CPR for 3 of 3 sampled staff (Staff C, Staff D, and Staff E). | Level D |
| Facility failed to ensure all direct care staff, including administrator or on-site manager, completed continuing education each year relevant to their job duties for 3 of 3 sampled staff (Staff C, Staff D, and Staff E). | Level D |
Report Facts
Number of sampled staff lacking certifications: 3
Number of sampled staff lacking continuing education: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in deficiencies for lacking current first aid and CPR certification and continuing education. | |
| Staff D | Named in deficiencies for lacking current first aid and CPR certification and continuing education. | |
| Staff E | Named in deficiencies for lacking current first aid and CPR certification and continuing education. | |
| Staff A | Interviewed regarding missing documentation and ongoing file review. | |
| Staff B | Mentioned as new to the community and involved in file review. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 18, 2025
Visit Reason
The purpose of this visit was to complete the compliance inspection and investigate intake #GA50003471.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA50003471; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 11, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00246775 with an on-site visit made on 7/11/2024 and the investigation completed on 7/12/2024.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00246775 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 26, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00239656 regarding a missing resident incident at Country Gardens Senior Living.
Findings
The facility failed to provide adequate oversight and safety measures to prevent elopement of a resident with cognitive deficits. The resident left the facility unnoticed through an unsecured back door without audible alarms, and the facility lacked a sign-in/sign-out policy. Law enforcement was involved, and the resident was not located.
Complaint Details
The investigation was triggered by intake #GA00239656 concerning Resident #1 who eloped from the facility on 10/1/2023. Law enforcement was called after a 30-minute search. Resident #1 was last seen around 12:40 p.m. and was not located. The resident had diagnoses including HIV positive, hypertension, and dementia. Staff interviews revealed lack of audible alarms on the back door and no sign-in/sign-out policy.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure the governing body provided oversight in compliance with applicable rules and regulations, resulting in a resident elopement incident. | SS= D |
| Facility failed to utilize effective safety devices to protect residents at risk of elopement; back door lacked audible alarms and locking mechanisms. | SS= D |
| Facility failed to ensure residents received adequate and appropriate care and services in compliance with federal and state law, as evidenced by failure to prevent elopement of a resident with cognitive impairments. | SS= D |
Report Facts
Number of sampled residents: 4
Resident admission date: Aug 4, 2023
Law enforcement response time: 1908
Door sensor alert time: 1512
Door sensor alert cleared time: 1513
Staff experience duration: 2
Resident care staff count: 3
Medication aide count: 1
Resident count: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding resident elopement, investigation, and facility safety policies | |
| Staff B | Responded to door sensor alert and involved in resident search | |
| Staff D | Interviewed about resident whereabouts and alarm system | |
| Staff F | Reported to law enforcement that Resident #1 suffered from dementia |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 8, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00225923.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00225923 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 14, 2021
Visit Reason
The purpose of the visit was to investigate intake #GA00218633, involving allegations that a facility employee posted pictures of residents on social media without their knowledge or permission.
Findings
The investigation found that the facility failed to respect the personal dignity of residents as staff posted pictures of residents on social media without their knowledge or permission.
Complaint Details
The complaint was substantiated based on interviews with staff and review of social media posts showing pictures of residents posted by a facility employee without permission.
Deficiencies (1)
| Description |
|---|
| Facility failed to respect the personal dignity of residents by posting pictures of residents on social media without their knowledge or permission. |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Jul 8, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00211811 and #GA00212046, with the investigation starting on 2021-02-23, an on-site visit on 2021-06-10, and completion on 2021-07-08.
Findings
The facility failed to ensure adequate and appropriate care for Resident #2 who eloped from the facility on 2021-02-07, unknown to staff until the resident was returned by an unidentified individual. The investigation revealed unsecured exit doors, lack of surveillance cameras, and insufficient monitoring, despite staff performing bed checks every two hours.
Complaint Details
The investigation was complaint-driven based on intakes #GA00211811 and #GA00212046. The complaint was substantiated by findings that Resident #2 eloped from the facility on 2/7/21 via an unsecured exit door, with staff unaware of the elopement until the resident was returned by an unidentified individual.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure each resident received adequate and appropriate care and services in compliance with federal and state law, evidenced by Resident #2 eloping from the facility unnoticed. |
Report Facts
Facility census: 30
Caregivers on duty: 2
Bed checks frequency: 2
Weather temperature high: 53
Weather temperature low: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding the incident and facility procedures | |
| CC | Responded to main entrance doorbell when Resident #2 was returned | |
| GG | Received call regarding elopement and provided background on Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 4, 2020
Visit Reason
The purpose of this inspection was to investigate intake #GA00209933.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation began 2020-11-30 and was completed 2020-12-04. No violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 26, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205126.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began on 2020-05-15 and was completed on 2020-05-26. No rule violations were found.
Inspection Report
Monitoring
Deficiencies: 0
Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess infection control process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 21, 2020
Visit Reason
The purpose of this visit was to investigate self reported intake #GA00202112.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of self reported intake #GA00202112 with no rule violations cited.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Nov 15, 2019
Visit Reason
An onsite visit was made to the facility on 11/15/19 to investigate complaint intake #GA00200671, which was started on 11/12/19 and completed on 11/15/19.
Findings
The facility failed to report a serious incident involving a resident who fell out of a wheelchair and required emergency care within 24 hours to the Department as required by regulation.
Complaint Details
Investigation was complaint-related, intake #GA00200671. The complaint was substantiated as the facility failed to report the serious incident as required.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report a serious incident using the complaint intake system within 24 hours following the occurrence of the incident for 1 of 38 residents. | SS= D |
Report Facts
Residents present during inspection: 38
Date of incident: Oct 6, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B interviewed regarding failure to report incident |
Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 20, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00199327, with an onsite visit made on 9/20/19 and investigation completed on 9/26/19.
Findings
The facility failed to maintain evidence of required trainings and skills competency for proxy caregivers for four residents, failed to keep floors, walls, and ceilings clean and in good repair as evidenced by soiled carpets in resident rooms, and failed to ensure adequate and appropriate care for one resident with unexplained bruising, which was investigated with multiple staff and physician interviews.
Complaint Details
Investigation of intake #GA00199327 regarding bruising on Resident #4. Multiple interviews and record reviews were conducted. The bruises were noted on 9/1/19, with physician reports and staff interviews indicating no known cause, and physician suggesting bruising may be due to bumping and thin skin. The facility could not explain the bruising.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain evidence of trainings, skills competency, and recertification as required by the Rules for Proxy Caregivers for Residents #2, #3, #5, and #6. | D |
| Failed to keep floors, walls, and ceilings clean and in good repair; carpets in rooms #201 and #204 were soiled with stains. | D |
| Failed to ensure each resident received adequate and appropriate care in compliance with applicable laws for Resident #4, who had unexplained bruising. | D |
Report Facts
Number of residents with missing proxy caregiver training: 4
Number of stained carpet areas observed: 3
Number of residents with care adequacy issues: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Stated no Proxy Caregiver training for four sampled residents | |
| Staff A | Stated carpet would be cleaned | |
| Staff G | Met with family of Resident #4 and stated facility did not know cause of bruises | |
| Staff D | Administered medication and eye drops to Resident #4 with no bruising observed at those times | |
| Staff F | Completed activities of daily living for Resident #4 with no bruises observed in morning | |
| AA | Visited Resident #4 and noted bruising, reported information about blood thinning | |
| BB | Observed bruises on Resident #4 and reported physician's explanation | |
| CC | Reported physician's opinion on bruising cause |
Inspection Report
Follow-Up
Deficiencies: 0
May 1, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 1/14/19 compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 1
Jan 22, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 08/07/18 compliance and complaint investigation with on-site visits made on 01/14/19 and 01/22/19.
Findings
The facility failed to ensure that only ambulatory residents capable of self-preservation with minimal assistance were admitted and retained, as evidenced by two sampled residents who required total assistance with ambulating, bathing, dressing, transferring, and grooming.
Complaint Details
This visit was a follow-up to a previous compliance and complaint investigation conducted on 08/07/18.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The home admitted and retained residents who were not ambulatory and not capable of self-preservation with minimal assistance, specifically Resident #5 and Resident #6 who required total assistance. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B interviewed on 01/22/19 stated Resident #5 and Resident #6 were not ambulatory and required total assistance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 21, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00190578.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Complaint #GA00190578 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 5
Aug 7, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00190308.
Findings
The facility failed to maintain minimum staffing ratios, ensure annual servicing of fire extinguishers, keep entrances and exits free of hazards, obtain timely medication refills for one resident, and include written waivers of the personal needs allowance for three residents.
Complaint Details
The visit was conducted to investigate intake #GA00190308. The complaint investigation found multiple deficiencies including staffing, safety, medication management, and documentation issues.
Severity Breakdown
D: 4
J: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain minimum on-site staff to resident ratio of one awake direct care staff per 15 residents during waking hours and one per 25 residents during sleeping hours. | D |
| Failed to ensure fire extinguishers were serviced annually for 6 of 6 fire extinguishers. | D |
| Failed to ensure entrances and exits were free of hazards such as equipment and debris. | D |
| Failed to obtain timely refills of prescribed medications resulting in interruption of routine dosing for 1 of 4 sampled residents. | J |
| Failed to include a written waiver of the personal needs allowance for 3 of 4 sampled residents. | D |
Report Facts
Census: 42
Direct care staff scheduled: 2
Fire extinguishers: 6
Residents without PNA waiver: 3
Sampled residents: 4
Inspection Report
Follow-Up
Deficiencies: 0
Dec 19, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the 8/30/17 complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up inspection to the 8/30/17 complaint investigation; no rule violations cited.
Inspection Report
Complaint Investigation
Census: 11
Deficiencies: 1
Aug 29, 2017
Visit Reason
The visit was conducted to investigate complaint #GA00178651 with an onsite visit on 8/29/17 and investigation completed on 8/30/17.
Findings
The facility failed to ensure residents were supervised consistent with their needs, particularly on the Memory Care Unit during staff breaks when only one staff member was present to supervise 10 residents. Two incidents of aggressive behavior between residents were documented, including one resulting in a resident fall and injury.
Complaint Details
The complaint investigation focused on supervision failures on the Memory Care Unit, with substantiated findings of inadequate supervision leading to resident altercations and injury.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents were not supervised consistent with their needs during staff breaks on the Memory Care Unit, leaving residents unattended and at risk. | D |
Report Facts
Residents present during incident: 11
Incident dates: 2
Medication dosage: 0.5
Medication frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Observed residents and reported being on break during incident; involved in supervision failure | |
| Staff C | Was off unit on break during incident; left residents unattended | |
| Staff D | Provided interview describing resident aggression patterns |
Inspection Report
Original Licensing
Deficiencies: 0
Jan 25, 2017
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No violations were cited as a result of this inspection.
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